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Care, Use, Maintenance and Discontinuation of Enteral Tubes (Adult & Pediatric) (2.20)

Care, Use, Maintenance and Discontinuation of Enteral Tubes (Adult & Pediatric) (2.20) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Gastrointestinal

2.20

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
August 31, 2017

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 2.20AP

Original
Revision

Page
1
of 11

Title: Care, Use, Maintenance and
Discontinuation of Enteral Tubes (Adult &
Pediatric)

I. PURPOSE

To provide guidance for the care, maintenance and discontinuation of enteral tubes,
including:
A. Tube Insertion, Tube Securement, and Initial Verification of Tube Placement
1. Short Term Enteral Tubes
2. Long Term Enteral Tubes
B. Routine Nursing Assessment, Ongoing Tube Placement Verification,
Troubleshooting
1. Short Term Enteral Tubes
2. Long Term Enteral Tubes
C. Decompression
D. Administration of Flushing, Medications and Fluids
1. Tubes Used for Decompression
2. Tubes Used for Feeding
E. Feeding via Enteral Tubes
F. Discontinuation of Enteral Tubes

II. DEFINITIONS

Enteral tubes are tubes placed directly into the gastrointestinal tract. The tube types
that are addressed in this policy are:
A. Short Term Tubes: These nasally or orally placed tubes are intended to be short
term or temporary (about 4-6 weeks of therapy). The tubes included in this
category are nasogastric (NG) tubes, orogastric (OG) tubes, and small bore
feeding (nasoduodenal [ND] or nasojejunal [NJ]) tubes placed either into the
stomach or small intestine.
B. Long Term Tubes: These percutaneous tubes are intended to be used for long-
term (longer than 4-6 weeks) or permanent enteral access. The tubes included in
this category are gastrostomy tubes (G-tubes, PEG tubes), jejunostomy tubes (J-
tubes, PEJ tubes), and gastrojejunal (G-J) tubes.

III. POLICY

All blindly inserted gastric tubes used for instilling feeding, fluids, or medications
should have radiographic (x-ray) confirmation before use, regardless of insertion
reason.



Page 2 of 11

IV. EQUIPMENT

Specific equipment is mentioned within the text below. Additional guidance about
equipment can be found in the “related” tab of this policy.

V. PRACTICE EXPECTATIONS

A. Tube Insertion, Tube Securement, and Initial Verification of Tube Placement
1. Short Term Enteral Tubes
Short Term Enteral Tubes
NG/OG Small bore (ND/NJ)
Insertion
• Follow instructions provided through
“Up to Date” reference under “tube
placement”.
• For NG tubes placed for
decompression, see also related
document.
• Document the insertion of tube by
adding the appropriate LDA in the
patient’s clinical record.

• At the Clinical Science Center
(CSC), these tubes will be
placed by the Feeding Tube
Team as outlined in Nursing
Patient Care Policy 2.25AP,
Placement of Small Bowel
Feeding Tube Using Cortrak
Enteral Access System and UW
Health Clinical Policy 2.3.6,
Small-bore Nasoenteric
(Dobhoff) Tube Placement.
o See exceptions for low
risk patients in policy
2.3.6.
• Tubes placed in pediatric
patients may be placed by
nurses.
• Tubes placed at The American
Center will be placed by Care
Team Leaders who have
demonstrated competency.
• Document the insertion of tube
by adding the appropriate LDA
in the patient’s clinical record.
• Document the appropriate
connector type within the LDA
to specify an ENFit feeding
tube versus a non ENFit feeding
tube.
Securement Ensure securement of enteral tube.
Suggested securement:
• NG tube securement: Dale tube
holder nasogastric (adult) (Central
Service [CS] Item Number 4008943)
o Change every three (3) days;
according to manufacturer’s
recommendations.
Ensure securement of enteral tube:
• If indicated, small bore enteral
tubes can be secured with a
nasal bridle, in accordance with
Nursing Patient Care Policy
2.24, Nasal Bridles: Use,
Maintenance and Removal.

Page 3 of 11

Short Term Enteral Tubes
NG/OG Small bore (ND/NJ)
• OG tubes may be secured to the
endotracheal (ET) tube.
Initial
Verification of
Placement
• Initial tube placement should be
confirmed with x-ray before the
instillation of feeding, fluids, or
medications.
• NG/OG tubes placed for
decompression require nursing
assessment for proper placement (e.g.
removal of gastric content); if
concern of malposition arises, an x-
ray should be obtained to verify
placement.
• Clinical guidance is provided in the
Nursing Algorithm: Initial Placement
Verification for Nasogastric (NG) &
Orogastric (OG) Tubes (see Related
section on U-Connect).
• When patients are admitted with an
existing short term enteral tube, the
device and function should be
assessed upon admission. Notify
provider if malposition is suspected
to determine the need for x-ray.
• Radiation exposure should be
considered and minimized as able,
while maintaining safe patient care.
• Initial tube placement should be
confirmed with x-ray before the
instillation of feeding, fluids, or
medications.
• Refer to policies 2.25AP and
2.3.6.
• When patients are admitted
with an existing short term
enteral tube, the device and
function should be assessed
upon admission. Discuss the
need for an x-ray with provider
team if tube is to be used for
feedings or if malposition is
suspected.
• Radiation exposure should be
considered and minimized as
able, while maintaining safe
patient care.

2. Long Term Enteral Tubes

Long Term Enteral Tubes
G-tube/PEG tube J-tube/PEJ tube
Insertion
• Insertion performed by provider.
• Document the insertion of tube by adding the appropriate LDA in the
patient’s clinical record.
• Document the appropriate connector type within the LDA to specify an
ENFit feeding tube versus a non ENFit feeding tube.
Securement Ensure securement of enteral tube.
Initial
Verification of
Placement
Initial verification conducted by provider via direct visualization.



Page 4 of 11


B. Routine Nursing Assessment, Ongoing Tube Placement Verification,
Troubleshooting
1. Short Term Enteral Tubes

Short Term Enteral Tubes
NG/OG Small bore (ND/NJ)
Routine Nursing
Assessment
• Assess tube during routine
assessment and document, at least
every 8 hours.
• Assess skin integrity at and around
nares or mouth; assess that the tube
holder is secure, that exposed skin is
intact and monitor for ulceration;
document.
• Document tube’s position using
“Mark and Measure” every 8 hours.
o “Mark” = external indicator
placed on the tube; recommend a
piece of waterproof tape (i.e.,
pink Hy-tape) placed near the
exit site.
o “Measurement” = if pre-printed
measurements are on the tube,
document the number closest to
the exit site. If there aren’t any
pre-printed measurements,
measure (with a tape measure)
the distance from the exit site to
the end of the tube, excluding
any valves or add on devices.
• Assess tube during routine
assessment and document, at
least every 8 hours.
• Assess skin integrity at and
around nares or mouth; assess
that the tube holder is secure,
that exposed skin is intact and
monitor for ulceration;
document.
• Document tube’s position using
“Mark and Measure” every 8
hours.
o “Mark” = external indicator
placed on the tube;
recommend using the nasal
bridle clip; if no nasal
bridle, use a piece of
waterproof tape (i.e., pink
Hy-tape) placed near the
exit site.
o “Measurement” = if pre-
printed measurements are
on the tube, document the
number closest to the exit
site. If there aren’t any pre-
printed measurements,
measure (with a tape
measure) the distance from
the exit site to the end of
the tube, excluding any
valves or add on devices.
Ongoing Tube
Location
Verification
• Nurses should be aware of the distal tip’s intended location.
• Clinical guidance for concerns about malpositioned tubes is provided in the
Nursing Algorithm: To Determine Malpositioning of Small or Large Bore
Gastric Tubes (see Related section on U-Connect).
Troubleshooting
• For clogged tubes, follow Nursing Patient Care Policy 2.22, Unclogging
Enteral Feeding Tubes, for guidance on unclogging the tube.
• Short term enteral tubes should be replaced at least as frequently as
recommended the manufacturer. Typically short term tubes should be not
left in for longer than 28 days.


Page 5 of 11


2. Long Term Enteral Tubes

Long Term Enteral Tubes
G-tube/PEG tube J-tube/PEJ tube
Routine Nursing
Assessment
• Assess the tube as outlined in
Nursing Patient Care Policies 2.17A,
Gastrostomy Care (Adult) and 2.17P,
Gastrostomy Care (Pediatric).
• Provide skin cares as outlined in
policies 2.17A and 2.17P.
• Inspect the skin at least once
every 8 hours for signs of
excoriation, erythema, drainage,
edema, bleeding, and tube
patency (absence of slits or
cracks that could lead to
leakage).
• Skin must be kept clean and dry
to prevent irritation and
infection.
Ongoing Tube
Location
Verification
• Nurses should be aware of the distal
tip’s intended location.
• Verify placement as outlined in
policies 2.17A and 2.17P.
Nurses should be aware of the
distal tip’s intended location.
Troubleshooting
• If this enteral tube becomes clogged,
follow policy 2.22 for guidance on
unclogging the tube.
• If this enteral tube needs to be
replaced, follow policy 2.17A or
2.17P.
• Complications (e.g., bleeding,
erosion, etc.) should be managed as
outlined in policies 2.17A or 2.17P.
If this enteral tube becomes
clogged, follow policy 2.22 for
guidance on unclogging the tube.

C. Decompression

Short Term Enteral Tubes: Nasogastric (NG) or Orogastric (OG) Tubes
Decompression Maintenance of blue “pigtail” air vent (See Salem Sumps: A Refresher– see
Related document on U-Connect)
• Never flush fluid through the blue air vent pigtail.
• Inject air through the blue air vent pigtail:
o before applying the anti-reflux valve,
o as needed for concerns about occlusion,
o and after irrigation/flushing of the NG/OG tube.
• Follow each irrigation or flush with an injection of air through the blue air
vent “pigtail”:
o Adults: use 15-30 mL of air
o Pediatrics: use 5-10 mL of air
o Neonates: use 1-3 mL of air
• The anti-reflux valve should be changed if it gets wet or soiled.
o The NG/OG tube will not function properly to decompress the stomach
if the valve becomes wet or obstructed.
o Visible gastric secretions in the vent lumen indicates an obstruction

Page 6 of 11

Short Term Enteral Tubes: Nasogastric (NG) or Orogastric (OG) Tubes
with gastric fluid. Check for adequate wall suctions, flush (if medically
appropriate) the tube, and/or attempt aspiration with irrigation set. After
clearing the obstruction, inject air through the blue air vent pigtail.
• Assess the suctioned contents for color, consistency and volume with each
routine assessment.
• Every 8 hours, check suction regulator gauge for proper pressure (usually
80 to 100 mmHg = low suction) and frequency (i.e., constant or
intermittent) according to provider order. Monitor and document color,
amount and rate of flow of drainage.
• The Dale ACE connector valve (CS Item Number 2227089) should be
changed as needed and at least every 30 days (per manufacturer’s
recommendation).
• If an enteral tube is on continuous suction, consider an alternate route for
medication administration. If it is necessary to administer medication via
the enteral tube, it is recommended to clamp the tube for at least 30 minutes
after administration to ensure medication has been properly absorbed.
• For suction set up guidance; refer to the “Step by Step Guide: Suction Set
Up” in the Related section on U-Connect.

D. Administration of Flushing, Medications, and Fluids

Short Term and Long Term Enteral Tubes
Tubes used for Decompression Tubes used for Feeding
Flushing /
Irrigation
• Flush the tube to maintain tube
patency. Use the following
process, unless otherwise
specified by provider order.
• Irrigation/flushing solution:
o Use sterile water with
patients who are immune-
compromised and/or
pediatric.
o Use tap water in all other
patients.
• Frequency:
o Flush per provider order;
typically every eight (8)
hours for adults and every
four (4) hours for pediatrics
with water
 30 mL for adults
 5-10 mL for
pediatrics
 1 mL for neonates
• Replace syringe and graduate
cylinder every 24 hours.
Replenish irrigant as necessary.
• Flush the tube to maintain tube
patency. Use the following process,
unless otherwise specified by
provider order.
• Irrigation/flushing solution:
o Use sterile water with patients
who are immune-compromised
and/or pediatric.
o Use tap water in all other
patients.
• Administer “free water” to replace
insensible water loss as ordered by
provider.
• Frequency:
o Flush every four (4) hours:
 During continuous
feedings
 Before and after
intermittent feedings
 After residuals are
checked
 Before and after
medication administration


Page 7 of 11

Short Term and Long Term Enteral Tubes
o ENFit compatible syringe
(Adults: 60 mL CS Item
Number 4012025;
Pediatrics: appropriately
sized syringe)
o Graduate cylinder (CS Item
Number 1207249)
o Label the graduate cylinder
and syringe with date and
time it was opened
• Never flush fluid through the
blue air vent pigtail. Inject air
through the blue air vent pigtail
using the slip-tip piston syringe
(CS Number 1209080):
o before applying the anti-
reflux valve,
o as needed for concerns
about occlusion,
o and after irrigation/flushing
of the NG/OG tube.
• Document irrigant and output in
I and O flowsheet.
o Flush with:
 30 mL for adults
 Pediatric and neonatal
patients, use lowest
volume necessary to clear
tube (typically about 5-10
mL for pediatrics and 1
mL for neonates)
• Replace syringe and graduate
cylinder every 24 hours. Replenish
irrigant as necessary.
o ENFit compatible syringe
(Adults: 60 mL CS Item Number
4012025; Pediatrics:
appropriately sized syringe)
o Graduate cylinder (CS Item
Number 1207249)
o Label the graduate cylinder and
syringe with date and time it was
opened
• Document irrigant, input, and output
in I and O flowsheet.
Medication
Administration
• Do not add medication directly to an enteral feeding formula.
• Extended release and enteric coated medications should never be crushed
and administered via enteral tube.
• For patients with numerous medications and/or patients with fluid
restrictions, it may be necessary to combine medications.
o Pharmacy and Clinical Nutrition may be consulted to help with this
process.
• Medication selection should be made in collaboration with provider and
pharmacist and based on the location of the tube’s tip.
• Restart the feeding in a timely manner to avoid compromising nutrition
status.
o Only hold the feeding for 30 minutes or more when separation is
indicated to avoid altered drug bioavailability.
• Use only oral/enteral syringes labeled with “for oral use only” to measure
and administer medication through an enteral feeding tube.
• For medication specific information in patients receiving continuous enteral
feeding, refer to the Dosing of Medications in Patients receiving Continuous
Enteral Feedings – Adult – Inpatient Clinical Practice Guideline.
• Syringes used for flushing the tube and administering medications must be
replaced every 24 hours.



Page 8 of 11


E. Feeding via Enteral Tubes

Short Term and Long Term Enteral Tubes
Tube Feeding
Administration:

Note:
Additional tube
feeding
guidance can be
found in these
two Clinical
Practice
Guidelines:
Enteral
Nutrition –
Neonatal &
Enteral
Nutrition -
Adult
• Tube placement must be verified (as outlined in Section A) before the
initiation of tube feeding.
• Provider order must be obtained before initiating feeding.
• Verify product matches provider order.
• If a powdered formula is reconstituted in advance, it should be immediately
refrigerated. Any unused formula must be discarded within 24 hours of
preparation.
• Bolus feedings administered via the barrel of a syringe should not be forced
by use of the plunger; allow gravity to promote the flow of the feeding.
• Bolus feedings should not be administered into tubes with a distal tip in the
small intestine.
• A closed tube feeding system (utilizing Spike sets) will be used whenever
possible.
• Administration Sets
o Change closed system sets every 48 hours
o Change open system sets every 24 hours
o Change administration sets for human milk every 4 hours. Refer to
Nursing Patient Care Policy 8.28, Human Milk Storage, for more
information.
o Empty and rinse feeding bag and tubing with tap or sterile water (for
immunocompromised and/or pediatric patients) between bolus or
intermittent feedings. Avoid topping off remaining formula.

• Formula Hang Times (also refer to this table)
2 hours 4 hours 8 hours 48 hours
• Homemade
blenderized
formula
• Human milk or
donor human milk
• Reconstituted
powdered formula
• Sterile formula
(neonates,
immunocompromi
sed infants)
• Non-sterile
additives
• Sterile
formula in
open
system
• Sterile
formula in
closed
(spiked)
system
Definitions:
• Homemade blenderized formula: real foods blended together to liquid
consistency (not commercially prepared)
• Sterile formula: commercially prepared ready-to-feed liquid formula
• Open system: pouring formula into plastic feeding bag
• Closed system: Sterile formula container that is spiked with the
administration set


Page 9 of 11

Short Term and Long Term Enteral Tubes
Tolerance of
Tube Feeding

Note:
Additional tube
feeding
tolerance
guidance can be
found in these
two Clinical
Practice
Guidelines:
Enteral
Nutrition –
Neonatal &
Enteral
Nutrition -
Adult
• Assess the patient every 8 hours for tolerance of enteral tube feeding. This
includes assessing passage of flatus and stool, patient complaints of pain or
nausea, elevated gastric residual volume (GRV), emesis, physical findings
such as abdominal distention and radiographic results (when available)
• Gastric residual should be checked every 4 hours for the first 48 hours of
initiation of tube feeding. After the initial 48 hours, non-critically ill patients
should have gastric residual checked every 8 hours; critically ill patients
should continue to have gastric residuals checked every 4 hours.
• In adults, if more than 250 mL of gastric residual are aspirated a second
time, notify practitioner to determine if feeding schedule should be changed
or a promotility agent should be considered. In the absence of other signs of
intolerance, it is not necessary to hold EN for residuals less than 500 mL. It
is recommended to hold enteral nutrition for residuals for greater than 500
mL.
• In pediatric patients, it is not recommended to routinely check gastric
residual volume. Signs of feeding intolerance in the pediatric patient are
emesis, retching, abdominal distention and fussiness. When checking
residuals, instill air before slowing drawing back. Small bore tubes may not
reliably produce a residual dependent on the bore size.
• Re-instill the residual volume back into the patient to prevent nutritional and
electrolyte depletion.
Feeding Safety
• Elevate the head of bed at least to 30 degrees, and preferably to 45 degrees,
for all patients receiving enteral nutrition unless a medical contraindication
exists.
• Use the reverse Trendelenburg position to elevate the HOB, unless
contraindicated, when the patient cannot tolerate a backrest elevated
position.
• Pediatrics: Safe Sleep practices and head of bed elevation must be
reconciled on a patient to patient basis weighing the risks and benefits.
• Assess all patients receiving enteral feeding for risk of aspiration.
• Assess feeding tolerance, gastric residual volumes, abdominal exam,
perform appropriate oral care, and monitor the external length of the tube as
frequently as every 4 hours to minimize risk of aspiration during feeding.
• Continue tube feeding when nursing care requires the head of bed to be
lowered for a brief period of time. Pause tube feeding if the head of bed
needs to be lowered for a prolonged procedure. Re-start feeding promptly
when the procedure is ended.
• Nurses should perform line reconciliation of tube feeding as outlined in
Nursing Patient Care Policy 14.33AP, Nurse-to-Nurse Change of Shift Hand
Off – Inpatient (Adult & Pediatric).



Page 10 of 11


F. Discontinuation of Enteral Tubes

Short Term Tubes Long Term Tubes
NG/OG Small bore (ND/NJ) G-tube/PEG tube
J-tube/PEJ tube
Discontinuation
of Tube
• Remove after
receiving
provider order.
Refer to Nurses
Guide to Clinical
Procedures,
Nursing
Procedure 7.18:
Discontinuing a
nasogastric tube.
• Remove after
receiving provider
order.
• Nasal bridle removal
as outlined in policy
2.24. Refer to
Nurses Guide to
Clinical Procedures,
Nursing Procedure
7.18: Discontinuing
a nasogastric tube.
Removal should be
performed by ordering
provider.


• Short term enteral tubes should be replaced
at least as frequently as recommended the
manufacturer. Typically short term tubes
should be not left in for longer than 28 days.


VI. UWHC CROSS REFERENCES

A. UW Health Clinical Policy 2.3.6, Small-bore Nasoenteric (Dobhoff) Tube
Placement
B. UW Health Clinical Policy 3.5.2, Screening, Assessment and Reassessment of
Patients
C. Nursing Patient Care Policy 2.17A, Gastrostomy Care (Adult)
D. Nursing Patient Care Policy 2.17P, Gastrostomy Care (Pediatric)
E. Nursing Patient Care Policy 2.22, Unclogging Enteral Feeding Tubes (Adult &
Pediatric)
F. Nursing Patient Care Policy 2.24, Nasal Bridles: Use, Maintenance and Removal
G. Nursing Patient Care Policy 2.25AP, Placement of Small Bowel Feeding Tube
Using Cortrak Enteral Access System (Adult & Pediatric)
H. Nursing Patient Care Policy 8.28, Breast Milk Storage
I. Nursing Patient Care Policy 14.33AP, Nurse-to-Nurse Change of Shift Hand-Off
– Inpatient (Adult & Pediatric)
J. Salem Sump Tubes: A Refresher (see Related section on U-Connect)
K. Step-by-Step Guide: Suction Set Up (see Related section on U-Connect)
L. Nursing Algorithm: Initial Placement Verification for Nasogastric (NG) and
Orogastric (OG) Tubes (see Related section on U-Connect)
M. Nursing Algorithm: To Determine Malpositioning of Small or Large Bore Gastric
Tubes (see Related section on U-Connect)
N. UW Health: Dosing of Medications in Patients Receiving Continuous Enteral
Feedings-Adult –Inpatient Clinical Practice Guideline
O. UW Health: Enteral Nutrition – Neonatal –Inpatient Clinical Practice Guideline
P. UW Health: Enteral Nutrition – Adult – Inpatient Clinical Practice Guideline

Page 11 of 11


VII. REFERENCES

A. Boullata, J.I., Carrera, A.L., Harvey, L., Escuro, A.A., Hudson, L., McGinnis, C.,
…ASPEN Safe Practices for Enteral Nutrition Therapy Task Force, American
Society for Parenteral and Enteral Nutrion. (2017). ASPEN Safe Practices for
Enteral Nutrition Therapy. Journal of Parenteral and Enteral Nutrition, 41(1),
15-103. doi: 10.1177/0148607116673053
B. Btaiche, I. F., Chan, L., Pleva, M., & Kraft, M. D. (2010). Critical illness,
gastrointestinal complications, and medication therapy during enteral feeding in
critically ill adult patients. Nutr Clin Pract, 25, 32-50. doi:
10.1177/0884533609357565
C. Gordon, M. (2011). Best evidence: Nasogastric tube placement verification.
Journal of Pediatric Nursing (26), 373-376.
D. Hodin, R. A., & Bordeianou, L. (2015). Nasogastric and nasoenteric tubes.
UpToDate. Retrieved from https://www-uptodate-
com.ezproxy.library.wisc.edu/contents/nasogastric-and-nasoenteric-
tubes?source=machineLearning&search=nasogastric%20tube%20placement&sele
ctedTitle=1~150§ionRank=1&anchor=H522921948#H522921948
E. Metheny, N. (2009). AACN practice alert: verification of feeding tube placement
(blindly inserted). American Association of Critical-Care Nurses. Retrieved from
http://www.aacn.org/WD/Practice/Docs/PracticeAlerts/Verification_of_Feeding_
Tube_Placement_05-2005.pdf

VIII. REVIEWED BY

Clinical Nurse Specialist, Research & Evidence-Based Practice
Clinical Nurse Specialist, General Medicine
Clinical Nurse Specialist, Surgical
Clinical Nurse Specialist, General Pediatrics
Clinical Nurse Specialist, Pediatric Universal Care Unit
Clinical Nurse Specialist, Trauma/Burn
Clinical Nurse Specialist, PACU
Clinical Nurse Specialist, Wound and Skin
Manager, Clinical Nutrition
Clinical Nutrition Specialist
Clinical Nutritionist, Clinical Nutrition, Adult
Clinical Nutritionist, Clinical Nutrition, Pediatrics
Nursing Patient Care Policy and Procedure Committee, August 2017

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive